pISSN 2383-9309❚eISSN 2383-9317 J Dent Anesth Pain Med 2015;15(2):85-92❚http://dx.doi.org/10.17245/jdapm.2015.15.2.85
Reliability and validity of the Korean version of the Dental Fear Survey Ah-Hyeon Kim1, Youn-Soo Shim2, So-Young Park3, Hee-Won Kim4, So-Youn An5 1
Department of dentistry, Dental spa Clinic, Daejeon, 2Department of Dental Hygiene, College of Health Science, Sunmoon University, 3 4 5 Asan, Department of Dental Hygiene, College of Health Science, Vision University, Jeonju, DoJang Middle School, Gunpo, Department of Pediatric dentistry, College of Dentistry, Wonkwang University, Daejeon, Korea Background: Many people experience varying levels of discomfort when confronted with the prospect of dental treatment. Dental treatment can be a traumatic experience, especially for children and adolescents with dental anxiety. In this age group, dental fear causes a significant problem in dental management and has been related to severe dental caries and dental pain. The Dental Fear Survey ( DFS ) is the most widely used measure of dental fear. This study was undertaken to develop the Korean version of the DFS ( K-DFS ) and test its reliability and validity. Methods: The K-DFS, which uses projective techniques to measure children’s and adolescents’ dental fear, was developed. The DFS was translated into Korean and participants were selected via convenience sampling. Reliability and validity were tested using data from a sample of 813 middle school students in Gyeonggi Province, selected from the Self questionnaire survey. The K-DFS was administered twice to 102 adolescents aged 12–15 years. Results: The K-DFS had high internal consistency reliability (99.1%) but low test-retest reliability. Conclusions: The results indicate that the Korean versions of the DFS have good internal consistency reliabilities and test-retest validities. However, we need to further examine the test-retest reliability of the K-DFS and replicate the current study in different samples covering various age groups. Key Words: Anxiety; Dental fear; Dental Fear Survey; Reliability; Validity.
3.3 in 2000, 2.2 in 2006, and 1.8 in 2012. The prevalence of caries was higher among females than males and in rural than urban areas [1-3]. Despite the observed
National oral health surveys are necessary to assess
decreasing trend in caries experience indicators in Korea,
treatment needs, monitor oral health, plan effective
the prevalence of caries is still considerably higher than
community intervention programs and health policies, and
that of other European countries as well as the targets
evaluate progress toward health objectives. In Korea, an
set by WHO within the Health 21 policy  framework.
epidemiological survey performed by trained, calibrated
Therefore, in Korea, there seems to be potential for caries
examiners has been carried out by the Ministry of Health
reduction. Community-based oral disease prevention
& Welfare every three years from 2000 to 2012. Dental
programs are urgently needed for the promotion of oral
caries were assessed according to the World Health
health. These differences remain when employment status
Organization diagnostic criteria. Decayed, missing, and
and/or income are controlled for, indicating that financial
filled surfaces and teeth (DMFS/DMFT) indexes were
disparities may not explain the higher caries rates,
estimated. The DMFT index for 12-year-old children was
especially gender differences in caries prevalence. Dental
Copyrightⓒ 2015 Journal of Dental Anesthesia and Pain Medicine
Received: 2015. 6. 24.•Revised: 2015. 7. 5.•Accepted: 2015. 7. 6. Corresponding Author: So-Youn An, Department of Pediatric dentistry, College of Dentistry, Wonkwang University, 77 Dun- San Dong, Seo- Gu, Dae-Jeon Metrocity, 320-120, Korea Tel: +82-42-366-1135 Fax: +82-42-366-1115 E-mail: [email protected]
Ah-Hyeon Kim, et al
fear is known to contribute to dental avoidance . One impact of not going to a dentist regularly is the increased likelihood of developing more serious dental problems, which may be manifested by the tendency to
2. Methods 2.1. Translation of the Dental Fear Survey
report that the most recent dental visit was due to pain
Kleinknecht’s 20-item Dental Fear Survey  was
or dental problem, compared with check-up . However,
translated from English into Korean, in accordance with
evidence on the relationship between oral disease and
the principles proposed by Gulliemin . The final
dental fear is mixed; some researchers have found that
version was created based on discussions among a dentist,
high dental fear is associated with more caries [6,7] while
a pediatrician, and an Oriental medicine doctor, all of
others have not . A higher number of missing teeth
whom had experience in conducting research with
and fewer filled teeth are more consistently reported in
children and adolescents. The English and Korean
fearful individuals [5-8], possibly due to a failure on their
versions of the DFS are included in the appendix.
part to obtain dental care until the carious teeth cannot be restored and must be extracted. Lee et al. found that
2.2. Characteristics of the Dental Fear Survey
in Korean adolescents, dental anxiety is related to oral
The DFS consists of a total of 20 items covering “visit
health behavior, the type of conditions they present with,
avoidance” (2 items), “triggers of physiological respon-
the treatment received, and dental caries experience.
ses” (5 items), “dental irritation during dental treatment”
Therefore, systematic programs that could relieve
(11 items), and “collective horror” (1 item). Items are
adolescents of dental anxiety should be developed .
self-rated and responses are made on a scale from 1 (not
To date, little is known about dental fear in Koreans.
at all) to 5 (very much). Each question is assumed to
Measures of dental fear appropriate for the Korean
have equal weight, and total scores are obtaining by
population would permit better epidemiological research
summing the scores to each question. Participants of this
as well as help in the evaluation of dental fear treatments.
cross-sectional study completed the questionnaires in
Self-report measures of dental fear are commonly used
writing at the study site on May 15, 2012. To assess
to permit quick assessment of the degree of dental fear
test-retest reliability, a follow-up survey was conducted
experienced by patients. Since there can be cultural
four weeks later, on June 18, 2012.
differences in various anxiety disorders, including dental fear [10,11], it is important to develop measures appropriate for different cultural groups. The aim of this study to translate the Dental Fear Survey into Korean for use with children and adolescents.
3. Statistical analysis 3.1. Data conversion Questionnaire responses were entered into an Excel database and checked for accuracy. No other changes
MATERIALS AND METHODS
were made to the original data. Only completed questionnaires were analyzed. Analyses were performed with
SPSS Version 19.0 (SPSS, Inc., Chicago, IL). A visual inspection showed that general DFS scores were not
The subjects were middle school students in a health
normally distributed. Relationships between variables
promoting school in Gunpo, Gyeonggi Province. A total
were therefore analyzed using the Mann–Whitney test and
of 813 students were enrolled in the first survey. Of these,
103 (12.55%) completed the second survey too.
J Dent Anesth Pain Med 2015 June; 15(2): 85-92
Korean version of the Dental Fear survey
3.2. Evaluation of reliability
calculating the correlation between participants’ self-
Reliability and validity testing is a common and nece-
rank-order correlation analysis because the data had a
ssary procedure in the development of research tools. In
skewed distribution (most participants had low fear
the present study, test-retest reliability was determined by
levels). Differences in responses to the question “were
calculating Spearman’s rank-order correlation coefficient
you ever frightened when you visited a dentist?” were
and Cohen’s kappa for the scores of the first and second
analyzed usinga chi-square test.
reported scores and observers’ ratings, using Spearman’s
survey. According to Spearman, a correlation coefficient
of 0.5 and over can be considered strong. Cronbach's alpha was used to determine internal consistency reliability.
3.3. Evaluation of validity
1. K-DFSscore distribution according to general characteristics
Generally, to determine validity, researchers test content validity, criterion validity and construct validity. In
K-DFS scores did not significantly differ by gender and
the present study, criterion validity was assessed by
grade (P > 0.05). Table 1 presents the summary statistics
Table 1. Distribution of scores on the Korean version of the Dental Fear Survey according general characteristics (n = 102)
Variable Total Sex Grade
Category Male Female st 1 nd 2 3rd
Dental Fear Survey average rank
62 40 18 10 74
49.40 54.75 49.25 55.65 51.49
P values were calculated using the Mann–Whitney test and Kruskal–Wallis test.
Table 2. Internal consistency reliability
Dental Fear Survey Questions 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Has fear of dental work ever caused you to put off making an appointment? Has fear of dental work ever caused you to cancel or not appear for an appointment? When having dental work done: My muscles become tense ... When having dental work done: My breathing rate increases ... When having dental work done:I perspire When having dental work done: I feel nauseated and sick to my stomach ... When having dental work done: My heart beats faster ... Making an appointment for dentistry ... Approaching the dentist’s office... Sitting in the waiting room ... Being seated in the dental chair … The smell of the dentist’ office … Seeing the dentist walk in ... Seeing the anesthetic needle ... Feeling the needle injected ... Seeing the drill ... Hearing the drill ... Feeling the vibrations of the drill ... Having your teeth cleaned ... All things considered, how fearful are you of having dental work done?
Amended Item-Total Correlation Coefficient 0.936 0.910 0.934 0.921 0.890 0.870 0.944 0.941 0.957 0.945 0.928 0.922 0.883 0.889 0.912 0.960 0.967 0.948 0.926 0.977
Cronbach's Alpha After Item is Eliminated 0.990 0.991 0.990 0.991 0.991 0.992 0.991 0.990 0.990 0.990 0.991 0.991 0.991 0.991 0.991 0.990 0.990 0.990 0.991 0.990
Alpha = 0.991, Standardized item alpha = 0.992 http://www.jdapm.org
Ah-Hyeon Kim, et al
for the K-DFS in each subgroup.
and “Seeing the anesthetic needle …” If an item was eliminated, the standardized Cronbach’s alpha barely
2. Reliability testing
changed. In the test-retest reliability analysis, items with
Cronbach’s alpha, a measure of internal consistency
Cohen’s kappa values below 0.4 or Spearman’s correla-
reliability, was very high for the total K-DFS, at 0.992
tion coefficients below 0.5 were eliminated. All results
(Table 2). Item-total correlations ranged between 0.990
are shown in Table 3.
and 0.992 and after adjustment, ranged between 0.883 and 0.977. The following had relatively low item-total
3. Criterion validity test
correlations: “When having dental work done: I perspire,”
The inspection result, Spearman correlation is -0.934~
“When having dental work done: I feel nauseated and
-0.960 to see a very high correlation. And about “Were
sick to my stomach…,” “Seeing the dentist walk in …,”
you ever frightened when you visited a dentist?”,we
Table 3. Test-retest reliability analysis (Cohen’s kappa and Spearman's rank-order correlation coefficient)
Dental Fear Survey Questions 1 Has fear of dental work ever caused you to put off making an appointment? 2 Has fear of dental work ever caused you to cancel or not appear for an appointment? 3 When having dental work done: My muscles become tense ... 4 When having dental work done: My breathing rate increases … 5 When having dental work done: I perspire 6 When having dental work done: I feel nauseated and sick to my stomach ... 7 When having dental work done: My heart beats faster ... 8 Making an appointment for dentistry ... 9 Approaching the dentist’s office ... 10 Sitting in the waiting room ... 11 Being seated in the dental chair … 12 The smell of the dentist’ office … 13 Seeing the dentist walk in ... 14 Seeing the anesthetic needle ... 15 Feeling the needle injected ... 16 Seeing the drill ... 17 Hearing the drill ... 18 Feeling the vibrations of the drill ... 19 Having your teeth cleaned ... 20 All things considered, how fearful are you of having dental work done?
Spearman' Rank-Order ** Correlation Coefficient
0.203 0.139 0.107 0.094 0.071 0.334 0.042 0.147 0.129 0.100 0.208 0.097 0.107 0.119 0.088 0.119 0.105 0.143 0.139 0.163
0.440 0.372 0.459 0.489 0.488 0.092 0.455 0.445 0.464 0.422 0.460 0.481 0.396 0.369 0.371 0.379 0.387 0.427 0.394 0.454
Chi-Squared Test* 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000
Spearman' Rank-Order Correlation Coefficient** -0.960 -0.960 -0.955 -0.934 -0.940 -0.942 -0.941 -0.941 -0.942
Kappa < 0.40: normal, 0.41–0.60: moderate, 0.61–0.80 good, > 0.81: very good Intra-class correlation coefficient ( ICC ) = 0.991 ** P > 0.05 *
Table 4. Criterion validity test
Dental Fear Survey Questions 1 2 3 4 5 6 7 8 9
Has fear of dental work ever caused you to put off making an appointment? Has fear of dental work ever caused you to cancel or not appear for an appointment? When having dental work done: My muscles become tense ... When having dental work done: My breathing rate increases ... When having dental work done: I perspire When having dental work done: I feel nauseated and sick to my stomach ... When having dental work done: My heart beats faster ... Making an appointment for dentistry ... Approaching the dentist’s office ... J Dent Anesth Pain Med 2015 June; 15(2): 85-92
Korean version of the Dental Fear survey
Table 4. Continued
Dental Fear Survey Questions 10 11 12 13 14 15 16 17 18 19 20 *
Sitting in the waiting room ... Being seated in the dental chair … The smell of the dentist’ office … Seeing the dentist walk in ... Seeing the anesthetic needle ... Feeling the needle injected ... Seeing the drill ... Hearing the drill ... Feeling the vibrations of the drill ... Having your teeth cleaned ... All things considered, how fearful are you of having dental work done?
P > 0.05,
Chi-Squared * Test 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000
Spearman' Rank-Order ** Correlation Coefficient -0.943 -0.942 -0.941 -0.942 -0.943 -0.943 -0.943 -0.942 -0.941 -0.941 -0.942
P > 0.05
answer a result of a response to category 20 is the
developed to improve the psychometrics and content
difference between a survey in both Statistically
validity of the original DAS. It consists of five items,
significant. It showed that the P < 0. 05 (Table 4).
and total scores may range from 5 (no fear) to 25 (highest level of fear). The MDAS has been found to be reliable
and valid in several samples from England, Scotland, Wales, Ireland, Finland Dubai, Brazil, and Turkey [15,21-24]. The DFS assess a broader array of dental
Generally measure of dental fear according adult po-
stimuli than the MDAS, such as seeing the drill, smelling
pulation, there were many methods, Corah Dental
the dental office, and the like. In addition, the respondent
Anxiety Scale (DAS) , Modified Dental Anxiety
is asked to rate specific physiological responses to dental
Scale (MDAS) , Weiner's Fear Questionnaire (FQ),
stimuli, such as muscle tension and increased breathing
Dental Anxiety Inventory (DAI)  and short dental
rates. Two items assess avoidance of dental appointments
anxiety inventory (S-DAI) , Dental Fear Survey
due to fear, and one item asks for an overall rating of
(DFS) , State-Trait Anxiety Inventory (STAI) ,
fear of dental work. Each item is rated on a 5-point scale.
Adolescents’ Fear of Dental Treatment Cognitive Inven-
Possible scores range from 20 (no fear) to 100 (highest
tory (AFDTCI) . Frequently the two most used
level of fear). The DFS has been found to be reliable
measures of overall dental fear in adults are Corah’s
and valid in samples of college students and dental
Dental Anxiety Scale (DAS)  and Kleinknecht’s
patients . The measure has been translated into a
Dental Fear Survey (DFS) .
number of languages, including Danish, Swedish,
The original DFS contained 27 items , which the
Norwegian, Hungarian, Brazilian, Turkish, Chinese and
authors later reduced to 20 . Both were originally
Malay [25-32]. To our knowledge, no Korean version of
developed in English. The original DAS is a 4-item
the DFS has been developed. Therefore, we elected to
questionnaire, asking respondents to rate their anxiety as
perform our own translation of this measure, and de-
they imagine approaching four dental stimuli, such as
veloped a Korean version of the DFS for use with
contemplating going to the dentist tomorrow. Each item
children and adolescents, with good construct validity.
is answered on a 5-point scale, so that scores may range
However, the K-DFS had unexpectedly low test-retest
from 4 (no fear) to 20 (highest level of fear). The
reliability (0.4; 95% CI = 0.34-0.85), measured by in-
Modified Dental Anxiety Scale (MDAS)  was
traclass correlation coefficients in a sample of middle http://www.jdapm.org
Ah-Hyeon Kim, et al
school students over a four-week interval. In conclusion, this study is the first to develop a Korean version of the DFS. We created and assessed a new
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Funding: The authors deny any conflicts of interest.
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of interest to disclose.
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Korean DFS items 1. 치과에 가는 것이 두려워서 치료날짜를 뒤로 미룬 적이 있다. 2. 치과에 가는 것이 두려워서 치료 약속을 취소한 적이 있다. 3. 치과에 들어서면 근육이 긴장되는 것 같다. 4. 치과에 들어서면 호흡이 빨라지는 것 같다. 5. 치과에 들어서면 진땀이 난 적이 있다. 6. 치과에 들어서면 구역질을 한 적이 있다. 7. 치과에 들어서면 심장이 쿵쾅거린다. 8. 치과 치료 약속을 정할 때면 두려움을 느낀다. 9. 치과에 도착 했을 때 두려움을 느낀다. 10. 대기실에서 치료를 기다릴 때 두려움을 느낀다. 11. 치료 의자에 앉아 치료를 기다릴 때 두려움을 느낀다. 12. 치과의 특유한 냄새를 맡았을 때 두려움을 느낀다. 13. 치과의사를 쳐다볼 때 두려움을 느낀다. 14. 마취용 주사바늘을 볼 때 두려움을 느낀다. 15. 주사바늘이 살을 찌를 때 두려움을 느낀다. 16. 치아 삭제용 기구(드릴)를 보고 두려움을 느낀다. 17. 치아 삭제용 기구가 돌아가는 소리를 들을 때 두려움을 느낀다. 18. 치아가 삭제되고 있는 느낌을 받을 때 두려움을 느낀다. 19. 치석을 제거(스켈링)할 때 두려움을 느낀다. 20. 위 사항들을 고려할 때 치과치료에 대한 전체적인 느낌은 나쁘다. English DFS items 1. Has fear of dental work ever caused you to put off making an appointment? 2. Has fear of dental work ever caused you to cancel or not appear for an appointment? When having dental work done: 3. My muscles become tense ... 4. My breathing rate increases ... 5. I perspire 6. I feel nauseated and sick to my stomach ... 7. My heart beats faster ... 8. Making an appointment for dentistry ... 9. Approaching the dentist’s office ... 10. Sitting in the waiting room ... 11. Being seated in the dental chair 12. The smell of the dentist’ office … 13. Seeing the dentist walk in ... 14. Seeing the anesthetic needle ... 15. Feeling the needle injected ... 16. Seeing the drill ... 17. Hearing the drill ... 18. Feeling the vibrations of the drill ... 19. Having your teeth cleaned ... 20. All things considered, how fearful are you of having dental work done?
J Dent Anesth Pain Med 2015 June; 15(2): 85-92